What is the appropriate management for costochondritis?

Management of Costochondritis

First-line treatment consists of NSAIDs for 1-2 weeks, with low-dose colchicine added if symptoms persist, after confirming the diagnosis through reproducible tenderness on palpation of the affected costochondral joints and excluding cardiac causes in appropriate patients. 1

Initial Diagnostic Confirmation Required

Before initiating treatment, you must confirm the diagnosis and exclude life-threatening conditions:

• Reproduce pain by palpating the costochondral joints (typically ribs 3-7, most commonly left-sided or retrosternal) - this is the hallmark diagnostic finding 1, 2
• Obtain an ECG within 10 minutes for patients >35 years or with cardiac risk factors to exclude acute coronary syndrome, aortic dissection, pulmonary embolism, or esophageal rupture 1
• Sharp, stabbing pain that worsens with inspiration or palpation markedly reduces the probability of cardiac ischemia 1
• Consider chest radiography to exclude rib fractures, infection, or neoplasm, though radiographs may miss costochondral abnormalities 3

Critical Pitfalls to Avoid

• Do not use nitroglycerin response as a diagnostic criterion - relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain 1
• Do not assume all reproducible chest wall tenderness is benign - coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness, and serious cardiac conditions can coexist with musculoskeletal findings 1, 4
• Do not delay cardiac evaluation in high-risk patients 1

Pharmacological Management Algorithm

First-Line Therapy

• NSAIDs for 1-2 weeks as initial pharmacological treatment 1, 2
• Acetaminophen can be used as an alternative if NSAIDs are contraindicated 1, 4

Second-Line for Persistent Symptoms

• Add low-dose colchicine if symptoms persist despite NSAID therapy 1, 2
• Topical analgesics (lidocaine patches) may provide localized pain relief with minimal systemic effects 1

Refractory Cases

• Local corticosteroid injections directed to the affected costochondral junction for refractory cases 3
• Analgesics (acetaminophen or tramadol) can be added for residual pain when NSAIDs are insufficient or contraindicated 3
• Do not use systemic corticosteroids for isolated costochondritis - there is no evidence supporting their use 3

Non-Pharmacological Approaches

• Apply ice or heat as adjunctive therapy 1, 2
• Stretching exercises show progressive significant improvement compared to control groups (p<0.001) and can be a useful instrument for treating these patients 5
• Advise patients to avoid activities that produce chest muscle overuse 4

Special Populations

• Axial spondyloarthritis patients: Costochondritis affects 30-60% and may be the first disease manifestation; monitor disease activity with composite measures 3
• Fibromyalgia patients: Consider multimodal therapy including cognitive behavioral therapy and low-dose amitriptyline 3
• Post-surgical patients: Pain is more common in those with postoperative infection or hematoma 2

Monitoring and Follow-up

• Reassess if symptoms persist beyond the expected self-limited course to rule out other potential causes of persistent pain 1
• Most cases are self-limiting and resolve within a couple of weeks 6
• Atypical costochondritis (not self-resolving) is associated with high medical expenses and psychological burden 6